The following writing sample is from an assignment in my third year Osteopathic Manipulative Medicine course. This was written within 24 hours and demonstrates a baseline competency in academic writing.
Please be advised that I am currently a medical student. The following research paper is not medical advice.
Please consider supporting the costs of this blog's website hosting by donating to my Venmo, @Ezra-Guttmann
Ezra Guttmann OMM: Acute Otitis Media in Pediatric Patients 10 February 2021 Using Osteopathic Manipulation to Treat Acute Otitis Media in Pediatric Patients
Acute otitis media has seemingly always been a tremendous source of burden for pediatric patients. UpToDate defines acute otitis media, which is often alternatively named purulent otitis media and suppurative otitis media, as “moderate to severe bulging of the tympanic membrane or new onset of otorrhea not due to acute otitis externa accompanied by acute signs of illness and signs or symptoms of middle ear inflammation.”(1) Although acute otitis media ranges in severity and recurs in some children more frequently than other pediatric patients, new research suggests that osteopathic manipulative medicine may be an effective adjuvant in the treatment of this burdensome illness.
Understanding the epidemiology and risk factors for acute otitis media in pediatric patients helps us define the illness and create a more focused treatment plan. Acute otitis media is in a league of its own in regards to prevalence: acute otitis media is the leading cause of urgent care visits in children, as well as the leading cause of antibiotic administration--thus forecasting the relative importance of employing osteopathic manipulative medicine as an adjuvant to better decrease the prevalence of antibiotic-resistant bacteria on a population level, in addition to decreasing the occasional severe effects of poorly treated acute otitis media. The illness prevails slightly more in the male pediatric population over the female population and makes a marked prevalence in children from 6 to 24 months of age 1. At the turn of the 21st century, the 7-valent pneumococcal conjugate vaccine (PCV7) became a powerful force against the acute otitis media’s prevalence in pediatric patients; moreover, the subsequent replacement with the 13-valent pneumococcal conjugate vaccine (PCV13) proved to be even more effective (1). The illness’ prevalence in early life suggests that the immature anatomy of the infant, including the short, floppy, and relatively horizontally-positioned Eustachian tube, is an ample factor at play. Speaking of “play,” doctors and scientists have postulated that day care settings increase the incidence of acute otitis media (1). Tobacco smoke exposure once again enters the conversation as a significant risk factor for the illness, although the mechanism is relatively unknown but has most recently been inferred to revolve around smoke creating a prosperous environment for otopathogens (1). Other risk factors implicate a background of “Native Americans, Alaskan and Canadian Inuit children, and indigenous Australian and Greenlander” in increased prevalence, as well as colder seasons (1). Our knowledge of microbiology drives modern medical care. Osteopathic manipulative treatment should only be introduced once the microbiology component is addressed. Bacteria appears most implicated for pediatric acute otitis media, followed by viruses. When isolated from middle ear fluid in children, S. pneumoniae, nontypeable H. influenzae, and Moraxella catarrhalis are the most common bacteria. The aforementioned vaccines have decreased the prevalence of S. pneumoniae (when extracted from tympanic fluid) and have guided increased prevalence of M. catarrhalis and non-typeable H. influenzae. S. pneumoniae is associated with the more clinically severe courses, including cases that render a child ill with bacteremia and mastoiditis (1). H. influenzae is reported to drive home over 50% of bacterial isolate from the middle ear fluid of young children and is notable in the increased mutations in its penicillin binding proteins, making this prominent bacteria particularly resistant to cephalosporins and ampicillin in certain parts of the world. Viral pathogens such as influenza, RSV and human metapneumovirus have also been implicated in acute otitis media, oftentimes superimposed on an existing bacterial otitis media (1).
Fortunately, antibiotic treatment has been largely effective for pediatric populations. UpToDate suggests using amoxicillin as the first-line therapy for pediatric patients with acute otitis media, exacting two doses that provides a child with 90 mg/kg per day of amoxicillin (2). When acute otitis media appears unresponsive to amoxicillin, amoxicillin-clavulanate (90 mg/kg per day of amoxicillin; 6.4 mg/kg per day of clavulanate---two doses) is the recommended therapy. Children with a penicillin allergy should be catered to based on the extent of their allergy: a patient with mild delayed reaction can be treated with antibiotics like cefdinir, cefpodoxime, cefuroxime, and even intramuscular ceftriaxone (2). A severe penicillin allergy, characterized by anaphylaxis, angioedema, urticaria, or bronchospasm, needs to be circumvented with a macrolide or clindamycin. Unfortunately, macrolides and clindamycins lack some efficacy and are getting increasingly resisted (2).
The full effect of acute otitis media and the opportunity afforded by an osteopathic adjuvant can be appreciated by evaluating the downhill complications of the illness. A history of recurrent acute otitis media has been associated with the formation of a cholesteatoma, which is an “abnormal growth of squamous epithelium in the middle ear and mastoid.” (3) These growths can induce conductive hearing loss. The pathogenesis of acquired cholesteatoma revolves around focal retractions of the tympanic membrane that form from chronic Eustachian tube dysfunction. Another common complication of poorly treated acute otitis media is mastoiditis (4), which is defined as infection of the mastoid air cells. This illness can be complicated by associated infection and destruction of the thin bony septae between air cells, as well as facial nerve paralysis.
Acute otitis media is therefore significant, alarming, and an issue that should be addressed preemptively; osteopathic manipulative medicine appears to be impactful. A study completed by Dr. Miriam V. Millis, MD, et. al investigated the effects of osteopathic manipulative medicine as an adjuvant to standard pediatric care in children with recurrent acute otitis media (5). Children six months to six years old were split into two groups: one group received osteopathic manipulative treatment in addition to routine care and the control group received solely routine care. The researchers found that the intervention group had a mean of 0.19 episodes of acute otitis media per month during the six month study as compared to the control group with a mean of 0.27 episodes per month. These results are consistent with a statistically significant reduction in antibiotics that needed to be prescribed for the intervention group (5). The generalizability of this study is certainly questionable, as there were only 57 patients in the study and only 25 intervention patients. The authors also report that there was a high rate of drop-out, which is understandable. Acute otitis media, even if it is a recurring problem, has a well-known reputation of being treated with antibiotics in a “once-and-done” way. Ascertaining compliance with an osteopathic manipulative medicine schedule is likely difficult for parents who believe that a child simply does not need such attention-to-detail manual treatment for a common childhood medical problem. A parent’s willingness to complete a child’s course of osteopathic manipulative medicine is likely also diminished upon realizing that even if there is moderate improvement in recurrence, access to an osteopathic physician and insurance coverage may be limited after the study. Additionally, a six month longitudinal study seems too short of a time frame to investigate a disease that has an established prevalence throughout childhood. There are many times in one’s childhood where a child may travel more or have more sick contacts; controlling for this within one half-year time frame is difficult. Nevertheless, osteopathic manipulative medicine appeared to be effective in acute otitis media in this small pediatric population.
A variety of osteopathic manipulative medicine techniques can be used to treat acute otitis media. According to Dr. Dawn Dillinger, DO and Dr. Kate Wessell, DO (6), a variety of techniques may be used. First off, the Galbreath Maneuver can be performed as a functional pump to allow the eustachian tube to drain. The technique is performed by the patient lying supine, and the physician standing at the head of the table with one hand on the forehead and another hand grasping the patient’s mandible. The child is instructed to open his/her mouth, and the physician deviates the mandible away from the affected ear and holds it there for three to five seconds. This technique is repeated three times in a similar pattern as standard muscle energy techniques. The efficacy of the Galbreath Maneuver was noted in a case study published in the Journal of the American Osteopathic Association (7), where a 14 month old female with recurrent acute otitis media, who actively had a bulging tympanic membrane that was non-movable with pneumatic otoscopy status-post oral antibiotics, was successfully treated through a 30 minute course of Galbreath Maneuver---reducing the child’s fever and decreasing the tympanic membrane’s edema and erythema.
Other techniques have been used to treat acute otitis media as well. The auricular drainage technique has been employed by osteopathic physicians in the past to move tympanic fluid (6). This maneuver is accomplished by the physician forming a “V” in their hand by separating their middle and ring fingers and placing the supine patient’s affected ear at the base of the V. With a supporting alternate hand at the other side, the physician rotates the myofascial layers in a clockwise motion and then reverses direction. Lymphatic pumping, where the osteopathic physician stands at the head of the table for a supine patient and rhythmically pulses the thoracic inlet to engage overall lymphatic flow, may also be used to further elucidate a therapeutic response. The holistic nature of the lymphatic system invites the greater idea of treating the overall sympathetic and parasympathetic drives that may aggravate the illness as well. A treatment would not be considered complete without assessing the position of the temporal bones, treating cervical spine dysfunction, evaluating tissue texture changes and treating somatic dysfunctions at T1-4 in order to adjust the sympathetic innervation to the head and neck. Effective cranial medicine can be performed to address the parasympathetic nervous system at CN II, VII, IX, and X, all of which contain preganglionic parasympathetic fibers.
Osteopathic manipulative treatment continually makes its mark on the practice of medicine. More studies with greater participant numbers are needed to make more accurate connections between the efficacy of using osteopathic manipulative treatment as an adjuvant for treating recurrent acute otitis media in pediatric patients. The aforementioned techniques intuitively make a lot of sense: the circular motions, the pumping, and the opening and closing of the eustachian tube. There is fluid in the ear, and it needs to be manually moved. At the end of the day, children with acute otitis media are often complaining of “fullness” in their ears or are simply pulling their ears; they feel real visceral discomfort and unfortunately may not feel relief of their symptoms for hours, if not days, after that doctor’s appointment. An osteopathic approach can effectively ameliorate a sizable amount of discomfort in the office, boost morale, and improve the patient-doctor relationship. A holistic assessment and plan of a child’s environment should be conducted to optimize the child’s treatment, which may include changing the setting of one’s daycare, avoiding second-hand smoke, treating for GERD (6), and potentially using xylitol as means of preventing acute otitis media in children (2). A physician’s approach that includes osteopathic manipulation medicine for common childhood ailments should not be viewed as a trailblazing phenomenon, but rather a gentle nod of the cap that gives reverence to modern-day antibiotics.
1 References Pelton, MD, Stephen, and Paula Tahtinen, MD, PhD. “Acute Otitis Media in Children: Epidemiology, Microbiology, and Complications.” UpToDate, 2021. UpToDate, www.uptodate.com/contents/acute-otitis-media-in-children-epidemiology-microbiology-and-co mplications?search=otitis%20media&topicRef=5959&source=see_link#H34. 2 Pelton, MD, Stephen. “Acute Otitis Media in Children: Treatment.” UpToDate, 2021. UpToDate, www.uptodate.com/contents/acute-otitis-media-in-children-treatment?search=otitis%20media&t opicRef=6021&source=see_link#H11. 3 Isaacson, Glenn. “Cholesteatoma in Children.” UpToDate, 2020. UpToDate, www.uptodate.com/contents/cholesteatoma-in-children?sectionName=SURGICAL%20TREAT MENT&search=otitis%20media&topicRef=5959&anchor=H16&source=see_link#H16. 4 Wald, MD, Ellen. “Acute Mastoiditis in Children: Treatment and Prevention.” UpToDate, 2019. UpToDate, www.uptodate.com/contents/acute-mastoiditis-in-children-treatment-and-prevention?search=otiti s%20media&topicRef=5959&source=see_link#H1. 5 Mills, Miriam V et al. “The use of osteopathic manipulative treatment as adjuvant therapy in children with recurrent acute otitis media.” Archives of pediatrics & adolescent medicine vol. 157,9 (2003): 861-6. doi:10.1001/archpedi.157.9.861 6 Dillinger, DO, Dawn, and Kate Ruda Wessell, DO. Osteopathic Manipulation for Acute Otitis Media in the Pediatric Population., https://certification.osteopathic.org/pediatrics/wp-content/uploads/sites/14/2017/09/pomt-acop-omt-aoam- module.pdf. PowerPoint Presentation. 7 Pratt-Harrington D. Galbreath technique: a manipulative treatment for otitis media revisited. J Am Osteopath Assoc 2000;100(10):635–639.
Comentários